Provider Demographics
NPI:1316548563
Name:CORREA-RIVERA, MAXWELL ALEXANDER
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:ALEXANDER
Last Name:CORREA-RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 MEADOW DALE CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95136-2055
Mailing Address - Country:US
Mailing Address - Phone:309-506-9170
Mailing Address - Fax:
Practice Address - Street 1:1171 HOMESTEAD RD STE 250
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-5485
Practice Address - Country:US
Practice Address - Phone:408-320-2590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician